title: Gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia: operative challenge or surgical dead end.
abstract: BACKGROUND
  Gangrene of the oesophago-gastric junction due to incarcerated hiatal hernia is an extremely uncommon emergency situation which was first recognized in the late nineteenth century. Early symptoms are mainly unspecific and so diagnosis is often considerably delayed. Aim of the study is to share experience in dealing with this devastating condition.
  
  
  METHODS
  We encountered three male patients with gangrene of the oesophago-gastric junction caused by strangulated hiatal hernia within the last years. Clinical symptoms, surgical procedures and outcomes were retrospectively analyzed. Furthermore, we provide a history outline on the evolving surgical management from the preliminary reports of the nineteenth century up to modern times.
  
  
  RESULTS
  Early symptoms were massive vomiting accompanied by retrosternal and epigastric pain. Hiatal hernia was already known in all patients. Nevertheless, clinical presentation was initially misdiagnosed as cardiovascular disorders. Upon emergency laparotomy gangrene of the oesophago-gastric junction was obvious while in one case even necrosis of the whole stomach occurred after considerable delayed diagnosis. Transmediastinal esophagectomy with resection of the proximal stomach and gastric pull up with cervical anastomosis was performed in two cases. Oesophago-gastrectomy with delayed reconstruction by retrosternal colonic interposition was mandatory in the case of complete gastric gangrene. Finally all sufferers recuperated well.
  
  
  CONCLUSIONS
  Strangulation of hiatal hernia with subsequent gangrene of the oesophago-gastric junction is a life-threatening condition. Straight diagnosis is mandatory to avoid further necrosis of the proximal gastrointestinal tract as well as severe septic disease. Surgical strategies have considerably varied throughout the last 100 years. In our opinion transmediastinal oesophagectomy with interposition of a gastric tube and cervical anastomosis should be the procedure of choice if the distal stomach is still viable. Otherwise oesophago-gastrectomy is unavoidable. Delayed cervical anastomosis or reconstruction is advisable in instable, septic patients.
authors.affiliation: Department of General and Thoracic Surgery, Klinikum Nuremberg Nord, Prof-Ernst-Nathan-Str. 1, 90419, Nuremberg, Germany, michael.schweigert@klinikum-nuernberg.de.
authors.forename: M
authors.initials: M
authors.lastname: Schweigert
authors.forename: A
authors.initials: A
authors.lastname: Dubecz
authors.forename: D
authors.initials: D
authors.lastname: Ofner
authors.forename: H J
authors.initials: HJ
authors.lastname: Stein
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004935:Esophageal Diseases / Q000209:etiology* / Q000266:history / Q000473:pathology / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects; D004943:Esophagogastric Junction / Q000473:pathology*; D005734:Gangrene / Q000209:etiology / Q000266:history / Q000473:pathology / Q000601:surgery; D005743:Gastrectomy; D006551:Hernia, Hiatal / Q000150:complications* / Q000266:history / Q000601:surgery; D049672:History, 19th Century; D049673:History, 20th Century; D006801:Humans; D008297:Male; D008875:Middle Aged; D009336:Necrosis / Q000209:etiology / Q000266:history / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies